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Insurance Nurse Reviewer Jobs (NOW HIRING)

HMSA

Nurse Reviewer - Clinical Review Unit

Kapolei, HI · On-site

Assists on inquiries from external parties such as the State Insurance Commissioner and from the ... The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

$75K - $95K/yr

The Utilization Management Authorization Review Nurse is responsible for managing inpatient ... Dental Insurance * Health Insurance * Life Insurance * Vision Insurance * Paid Time Off ...

Astiva Health

UM Nurse Reviewer

Orange, CA · On-site

$75K - $95K/yr

The Utilization Management Authorization Review Nurse is responsible for managing inpatient ... Dental Insurance * Health Insurance * Life Insurance * Vision Insurance * Paid Time Off ...

Zimmerman Associates, Inc.

$23.56/hr

Referral Management (Non-Nurse) Reviewers will facilitate centralized product line and specialty ... Processing/Insurance Referral * U.S. Citizenship required, with the ability to obtain a Public ...

Dane Street

PRN Utilization Review Nurse Reviewer

Utilization Management Nurse Reviewers collaborate with healthcare providers, insurance companies, and patients to optimize healthcare delivery, control costs, and maintain quality care. Their ...

Care Navigators On Demand

We currently have an opening for Clinical Nurse Reviewer The Clinical nurse reviewer will ... We offer a generous PTO package, 401k Retirement Savings, Life Insurance, Flexible Spending Account ...

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How much do insurance nurse reviewer jobs pay per hour?

As of Sep 2, 2026, the average hourly pay for insurance nurse reviewer in the United States is $37.04, according to ZipRecruiter salary data. Most workers in this role earn between $34.13 and $41.35 per hour, depending on experience, location, and employer.

What is an insurance nurse reviewer?

An Insurance Nurse Reviewer is a licensed nurse who evaluates medical claims to ensure they meet policy guidelines and medical necessity. They review patient records, treatment plans, and healthcare provider documentation to determine coverage eligibility. Their role helps insurance companies manage costs while ensuring patients receive appropriate care. Strong clinical knowledge and attention to detail are essential for assessing claims accurately.

What does an insurance nurse reviewer do?

On a typical day, an Insurance Nurse Reviewer spends much of their time reviewing patient medical records, evaluating insurance claims for medical necessity, and documenting their findings in detail. The role often involves collaborating with physicians, case managers, and adjusters to clarify information or seek additional insights when necessary. You may also participate in team meetings to discuss complex cases, ensure adherence to regulatory standards, and stay current with evolving policies. The work is largely independent but requires strong communication skills and a systematic approach to managing multiple cases effectively.

What are the key skills and qualifications needed to thrive as an insurance nurse reviewer?

To thrive as an Insurance Nurse Reviewer, you need a current nursing license, clinical experience, and a strong understanding of medical terminology and claims review processes. Familiarity with utilization review software, health insurance claims systems, and URAC or CM certification is often required. Attention to detail, critical thinking, and effective written and verbal communication skills help you excel in this position. These qualifications and abilities are vital for accurately evaluating medical records, ensuring compliance, and making informed decisions regarding healthcare coverage.

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Insurance Nurse Reviewer jobs near you
Infographic showing various Insurance Nurse Reviewer job openings in the United States as of August 2026, with employment types broken down into 92% Full Time, and 8% Part Time. Highlights an 62% In-person, 15% Hybrid, and 23% Remote job distribution, with an average salary of $77,034 per year, or $37 per hour.

Nurse Reviewer - Clinical Review Unit

HMSA

Kapolei, HI • On-site

Other

Posted 13 days ago

Job description

  1. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
  2. Demonstrate understanding and application of over 250 Guide to Benefits, Evidence of Coverage, Plan Brochure, and Member Handbook. HMSA annually updated medical and drug policies, medical protocols, National Comprehensive Cancer Network, Milliman Care Guidelines, Drugdex, etc. to determine the medical necessity of urgent and non-urgent precertification requests. Urgent requests must be completed within 72 hours and non-urgent requests within 15 calendar days.
  3. Use clinical judgment, medical necessity guidelines and plan benefits to determine approval, potential denial or alternative treatment of each urgent or non-urgent precertification request. Settings include inpatient, outpatient, in-state, out-of state and out-of country.
  4. Document clinical case summary and review outcome of each review appropriately to meet regulatory and program requirements.
  5. Review various types of services, including but not limited to:
    • Transplants
    • Air Ambulance
    • Chemotherapy
    • Clinical trials
    • Genetic testing
    • Cancer treatments/radiation therapy
    • Experimental/Investigational Services/Devices
    • New Technology
  6. Utilize medical necessity criteria from established medical policies and clinical practice guidelines to render precertification determinations as described in the Medical Management UM work plan. This detailed clinical judgment includes evaluating whether the requested service is a covered benefit under the member's health plan, is medically appropriate for the member's clinical condition or whether the request requires referral to a Medical Director for potential denial of the request. The Nurse Reviewer must follow each line of business' requirements and each accrediting body's (CMS, NCQA, HSAG) requirements for each request. Assists on inquiries from external parties such as the State Insurance Commissioner and from the Legal Department. Responsibilities include, but are not limited to:
    • Call providers when additional clinical information is required to clarify or complete a complex precertification determination.
    • Approve precertification requests based on clinical judgment using criteria, medical record documentation and other information received from the provider.
    • Consult with Medical Directors on requests which do not meet clinical criteria and offer alternative covered health care options as appropriate.
    • Consult Medical Directors on potential quality issues identified during review of medical records. Refer cases to Integrated Health Management, Pharmacy Department or Benefits Integrity Department depending on the concern.
  7. Evaluate suspended claims against medical records to determine the medical necessity and appropriateness of medical services, identify irregularities such as over or under-utilization of services, potential up-coding, over billing, etc.
  8. Communicate timely, accurate information either verbally, electronically or in writing using clinical judgment, knowledge of medical/reimbursement policies and plan benefits to providers, members as well as internal MM staff and other internal departments (Claims Administration, Customer Relations, Provider Contracting, etc.). For denied services, ensure the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
  9. Identify and refer members with specific medical and/or behavioral health needs or complex case management and collaborate with medical and behavioral case management staff. Identify and refer quality of care issues and suspected fraud, waste or abuse to the appropriate departments.
  10. Perform pre-screening assessment of incoming pre-certification requests to ensure appropriateness of review. Advises non-clinical staff on clinical and coding questions to ensure correct system processes and entries.

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